SPR Unknown #47 -- FINAL

Thangamadhan Bosemani MD

Jane Benson MD

Johns Hopkins University School of Medicine

Keywords

SPR Unknown 47, duodenal web, duodenal diaphragm


Publication Date: 2011-03-09

History

month old male presenting with failure to thrive, persistent forceful and non-bilious vomiting.

Findings

Scout Radiograph (Image 1): Moderate gaseous distension of the stomach and air filled proximal duodenum, consistent with a “double bubble configuration”. Moderate amount of stool is present in the visualized colon and rectum.

Upper GI examination (Images 2 – 3): Image 2 in RAO position demonstrates gastroesophageal reflux, peristaltic wave in the stomach with a normal pyloric channel and dilated contrast filled proximal duodenum. An abrupt change in the caliber of the duodenum from the dilated proximal segment to relative normal caliber is seen. The distal normal caliber duodenum crosses the midline to reach the duodenojejunal junction, which is in a normal position.

Diagnosis

Fenestrated duodenal web

DDx

Duodenal atresia/stenosis, Annular pancreas

Discussion

Duodenal web is a rare developmental anomaly and a cause for partial duodenal obstruction. Most of the webs occur proximal to or near the ampulla of Vater in the second part of the duodenum, with a small percentage proximal to the ligament of Treitz. The severity of obstruction from the web is variable and the clinical presentation can occur anytime from infancy to adulthood. Clinical presentation of vomiting and failure to thrive is typical in children. Bilious emesis is related to the position of the web and ampulla of Vater

Duodenal atresia and annular pancreas frequently present soon after birth with complete obstruction.

Radiological findings: The plain radiograph shows a “double bubble appearance” with air in the dilated stomach and proximal duodenum. Upper GI examination demonstrates a dilated proximal duodenum filled with contrast and associated peristalsis in the stomach. There is an increased risk of aspiration due to gastroesophageal reflux, secondary to the partial obstruction. A web may appear as a linear lucency in the barium column and may balloon more distally within the lumen of the duodenum to produce a windsock deformity. A jet of contrast beyond the dilated segment is suggestive of a fenestration and hence incomplete obstruction.

Plain radiography and Upper GI contrast examination remain essential tools in the diagnosis of duodenal webs in children.

References

  1. Congenital Anomalies of the Upper Gastrointestinal Tract Teresa Berrocal, et al. July 1999 RadioGraphics, 19, 855-872
  2. Pediatric gastrointestinal imaging and intervention, Volume 1 By David A. Stringer, Paul S. Babyn pages 332-338.

3 images